CIGNA DENTAL OPEN ENROLLMENT BROCHURE. State of Connecticut Retirees

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1 CIGNA DENTAL OPEN ENROLLMENT BROCHURE State of Connecticut Retirees Offered by: Cigna Health and Life Insurance Company, Cigna HealthCare of Connecticut, Inc., or their affiliates /16

2 You and your family have the opportunity to receive dental care through one of the following State of Connecticut dental plans: Basic Plan Enhanced Plan Dental HMO (DHMO) Learn More. Choose Well. Make sure that you don t miss your opportunity to enroll for this important benefit. Review your plan materials and consider your family s needs. Access your dental benefit information at: the website developed by Cigna just for State of Connecticut retirees. We re there for you when and how you need us. Call us: Cigna24 Customer Service hours include weekdays, Saturdays, Sundays and holidays. Call us at Cigna24 any time you need us we ll be there. We re on the clock for you 24 hours a day, 7 days a week, 365 days a year. We are here to help answer questions like: I live half the year in Florida and the other half in Connecticut. Will I have access to providers? My dentist told me I need a root canal. Does my dental plan cover this? Visit us online: Customized website developed by Cigna just for State of CT retirees with: Information on plan specifics Help finding participating dentists and specialists Programs and plan features available to you MyCigna.com Completely personalized, so it s easy to quickly find what you re looking for. Plan information Network directory of dentists Oral Health assessments and quizzes Out-of-pocket dental cost estimates ID Card info Claim information Discounts on a variety of health and wellness products and services 1 Always on the go? You can also use many of the above services on the mycigna mobile app! 2 1. Healthy Rewards is a discount program. If your plan includes coverage for any of these services, this program is in addition to, not instead of, your plan benefits. Healthy Rewards programs are separate from your benefits. A discount program is NOT insurance, and you must pay the entire discounted charge. Some Healthy Rewards programs are not available in all states and programs may be discontinued at any time 2 Programs to Support Your Overall Health Your health. Our focus. In the real world, you have to balance your time, commitments and priorities. At Cigna, we keep our focus on helping you live healthier. Value-added programs, such as wellness and discount programs are included with your Cigna dental plan. Cigna Dental Oral Health Integration Program Research shows an association between oral health and overall health. 3 With the right oral health care, and regular medical treatments, high-risk individuals may be able to improve their overall health. With this program, eligible members with certain medical conditions may receive 100% reimbursement of their out-of-pocket costs for select covered dental services. 4 The qualifying medical conditions for this program are: Heart disease Stroke Diabetes Pregnancy You will find the registration form and instructions at the back of this book. For additional information regarding this program please visit Cigna Healthy Rewards Cigna s Healthy Rewards 1 Program gives discounts on healthy programs, products and services. There s no time limit or maximum. Just visit a participating provider or shop online to enjoy these instant savings. No referrals or claim forms are needed. The following Healthy Rewards programs are available: Weight and nutrition management Fitness Tobacco cessation Vision and hearing care Chronic kidney disease Organ transplants Head & neck cancer radiation Vitamins, health and wellness products Alternative medicine Anticavity products Healthy lifestyle products After you enroll in one of the Cigna Dental insurance plans, you can learn more about Healthy Rewards by visiting cigna.com/stateofct (Click on Protect Your Dental Health), (Password: savings) or by calling The downloading and use of the mycigna Mobile App is subject to the terms and conditions of the App and the online stores from which it is downloaded. Standard mobile phone carrier and data usage charges apply. 3. Appropriate Periodontal Therapy Associate with Lower Medical Utilization and Costs. Presented at the International Association for Dental Research Meeting March 2013, Seattle 4. You do not need to meet your plan s deductible to receive reimbursement for these services. However, any reimbursement you receive will apply to and is subject to your plan s annual maximum. If you have coverage for out-of-network services you may choose to visit an in-network or out-of-network dentist. However, remember that it s a good idea to use an in-network (Participating) dentist. Participating dentists have a contract with Cigna. This means you pay less.

3 Your Dental Plan Choices at a Glance Basic Plan This plan allows you to visit any dentist or specialist. Enhanced Plan This plan offers dental services both within and outside of a network of dentists and dental specialists without a referral. However, your out-of-pocket expenses may be higher if you see an out-of- network provider. Dental HMO (DHMO) Plan This plan provides in-network dental services. You must select a Primary Care Dentist (PCD) to coordinate all care and referrals are required for all specialist services. BASIC PLAN (ANY DENTIST) 3 ENHANCED PLAN (NETWORK) DHMO PLAN (NETWORK ONLY) Annual Deductible None $25/individual, $75/family None Annual Maximum None (Maximum $500 per person Maximum $3,000 per person None for periodontics) 2 (Excluding orthodontics) Exams, Cleanings, and X-rays Covered at 100% Covered at 100% 1 Covered at 100% Periodontics: 2 Periodontal Maintenance Periodontal Scaling and Root Planing Covered at 80% Covered at 50% (To a maximum of $500) Covered at 100% Covered at 80%, after deductible Covered 3 Covered 3 Simple Restoration (Fillings) Covered at 80% Covered at 80% Covered 3 Oral Surgery Covered at 67% Covered at 80% Covered 3 Major Restoration (Crowns) Covered at 67% Covered at 67% Covered 3 Dentures, Fixed Bridges Covered at 50% Covered at 50% Covered 3 Implants Not covered 4 Covered at 50% ( To a maximum of $500) Covered 3 Orthodontia Not covered 4 Maximum: $1,500 per person per lifetime Covered 3 1. In the Enhanced plan be sure to use an in-network dentist to ensure receiving 100% coverage; with out-of-network dentists, you will be subject to balance billing if your dentist charges more than the maximum allowable charge. 2. If enrolled in the Health Enhancement Program: No annual maximum on services for periodontal maintenance (Limit 2 per calendar year) or scaling and root planing (Frequency limits and cost shares may still apply). Please also note the periodontal cleaning is covered at 100%. 3. Contact Cigna at for patient co-pay amounts 4. While not covered, you will get the discounted rate on these services if you visit a network dentist, unless prohibited by state law Sample Out-of-Pocket Costs for Common Dental Procedures Here s a comparison of sample out-of-pocket costs for common dental procedures under each State of Connecticut dental plan option. Keep in mind this information is for illustrative purposes only and that costs may differ based on your dentist and/or geographic location. These costs are based on average in- and out-of-network dental fees within the State of Connecticut. DENTAL PROCEDURE/TREATMENT BASIC PLAN (ANY DENTIST) In- Network Out-of- Network ENHANCED PLAN (NETWORK) In- Out-of- Network Network DHMO PLAN (NETWORK ONLY) Network Only Oral Exam $0 $0 $0 $0 $0 Bitewings four films $0 $0 $0 $0 $0 Routine Cleaning Adult $0 $0 $0 $0 $0 Routine Cleaning Child $0 $0 $0 $0 $0 One Posterior Composite Filling (Two Surface) $61.80 $94 $67 $ $53 One Amalgam Fillings (Two Surface) $21 $46 $21 $ $5 Simple Extraction Performed by General Dentist $24 $49.20 $24 $ $11 One Completely Bony Impaction Performed by Oral Surgeon $129 $204 $78 $395 $175 Deep sedation/general anesthesia first 30 minutes $305 $480 $61 $236 $160 Crown Core buildup, including any pins Crown Porcelain fused to high noble metal Total Comprehensive Orthodontic Treatment Adolescent: Includes Pre-Orthodontic Treatment Visit, Orthodontic Treatment Plan and Records, Banding, 24-Month Treatment Fee, Removal of Appliances, and Retention $192 $296 $488 $374 $478 $852 $63 $296 $360 $272 $978 $1,250 $93 $410 $503 $6,273 $6,273 $3,379 $4,773 $3,811 These are only the highlights. Review the information in this guide for additional details, including related plan exclusions and limitations.

4 Coverage for Fillings under the Basic and Enhanced Plan There s not always one simple answer for treating a dental condition. You and your dentist should discuss the various options, and then you can decide on the best approach. Your costs may vary based on the treatment plan you choose. The Basic and Enhanced Plans provide coverage for amalgam (silver) fillings only on posterior (Back) teeth. If you decide to get a composite (white) filling on a posterior tooth, you ll be responsible for paying the dentist the difference between the silver filling covered by the plan and the more expensive restoration. Both of these methods are recognized by the dental profession as acceptable treatment plans; however, the silver filling is the least costly alternative for treatment. Coverage for Bridges, Crowns, and Dentures under the Basic and Enhanced Plan Replacement of bridge, crown or dentures will not be covered if it is replaced within seven years of the original installation date unless the following is occurs: the replacement is made necessary by the placement of an original opposing full denture or the necessary extraction of natural teeth; or the bridge, crown or denture. No coverage for replacement of crowns if damage or breakage was directly due to provider error. This type of replacement is the responsibility of the Dentist. If replacement is necessary because of patient non-compliance, the patient is liable for the cost of replacement. Savings on Non-Covered Services Many of our Basic or Enhanced DPPO network dentists have agreed to offer network discounts to you and your covered dependents for non-covered services. These savings may also apply to services that would not be covered because you reached your annual benefit maximum, or due to other plan limitations such as frequency, age or missing tooth limitations.* You can obtain savings on most services not covered under the Basic or Enhanced plans.* You must visit network dentists in order to take advantage of the Cigna Dental PPO network discounts. Savings will not apply if you or your covered dependents visit a non-participating dentist. You must verify that a procedure is listed on the dentist s fee schedule prior to receiving treatment You are responsible for paying the negotiated fees directly to the dentist. * Discounts on non-covered services may not be available in all states. Certain dentists may not offer discounts on non-covered services. Please speak with your dental care professional or contact Cigna member services prior to receiving care to determine if these discounts will apply to you. 4

5 STATE OF CONNECTICUT BASIC PLAN Effective Date: July 01, 2016 This is a summary of benefits for your dental plan. Maximum CIGNA DENTAL NETWORK BENEFITS Periodontics $500* All Categories Except Periodontics Unlimited Calendar Year Deductible $0 Preventive & Diagnostic Care Cleanings Limit: Two per calendar year Oral Exams Limit: Two per calendar year Bitewing X-Rays Limit: One per calendar year Basic Restorative Care Fillings** Fluoride Application- Under age 16 two per calendar year Sealants Under age 16, one treatment per tooth every three years Non-Routine X-Rays Limit: Once every five calendar years Brush Biopsy Emergency Care to Relieve Pain Oral Surgery Simple Extractions Root Canal Therapy/Endodontics Stainless Steel/Resin Crowns Limit: Replacement every seven years Relines, Rebases, and Adjustments Allowable six months after install Repairs Bridges, Crowns, and Inlays Repairs Dentures Major Restorative Care Crowns/Inlays/Onlays Replacement every seven years Surgical Extraction of Impacted Teeth Oral Surgery All Except Simple Extraction Space Maintainers (Limited to non-orthodontic treatment) Plan Pays Periodontics Maintenance 80%** Periodontal Scaling and Root Planning* 50%, to a maximum of $500* Periodontics All Others Osseous surgery Clinical Crown Lengthening Bone Replacement Graft Gingivectomy Full Mouth Debridement Pretreatment Review 100% 80% 67% 50%, to a maximum of $500* Voluntary basis when extensive work in excess of $200 is proposed. * If enrolled in HEP, maximums are waived on Periodontal Maintenance, Periodontal Scaling and Root Planning procedures. ** For fillings other than amalgam, an alternate benefit may apply. If enrolled in HEP, Periodontal Maintenance is covered at 100%. Where allowed by state law, in-network providers will charge no more than negotiated rate for non-covered services Please refer to the Summary Plan Description posted at for a full list of covered benefits, exclusions and limitations.

6 Procedure CIGNA DENTAL PPO/INDEMNITY EXCLUSIONS AND LIMITATIONS Exclusions & Limitations Exams Two per calendar year Prophylaxis (Cleanings) Two routine and two periodontal cleanings per calendar year Fluoride 2 per calendar year for people under 16 X-Rays (routine) Bitewings: 1 per calendar year X-Rays (Non-routine) Full mouth: 1 every 5 calendar year. Panorex: 1 every 5 calendar year General Anesthesia Not covered Minor Perio (Non-surgical) Various limitations depending on the service, Frequency limit of once per 24 months Perio Surgery Various limitations depending on the service, Frequency limit of once per 36 months Crowns and Inlays Replacement every 7 years Crowns Over Implants 1 per every 7 years if unserviceable and cannot be repaired. Benefits are based on the amount payable for non-precious metals. No porcelain or white/tooth colored material on molar crowns or bridges. Bridges Not covered Dentures and Partials Not covered Relines Covered if more than 6 months after installation Adjustments Covered if more than 6 months after installation Repairs - Bridges Reviewed if more than once Repairs - Dentures Reviewed if more than once Sealants Limited to posterior tooth. One treatment per tooth every three years up to age 16 Space Maintainers Limited to non-orthodontic treatment Alternate Benefit When more than one covered Dental Service could provide suitable treatment based on common dental standards, Cigna HealthCare will determine the covered Dental Service on which payment will be based and the expenses that will be included as Covered Expenses. Benefit Exclusions: Services performed primarily for cosmetic reasons Replacement of a lost or stolen appliance Procedures, appliances or restorations whose main purpose is to change vertical dimension, diagnose or treat conditions of TMJ, stabilize periodontally involved teeth, or restore occlusion Veneers of porcelain or acrylic materials on crowns or pontics on or replacing the upper and lower first, second and third molars Bite registrations; precision or semi-precision attachments; splinting Instruction for plaque control, oral hygiene and diet Implants Dental services that do not meet common dental standards Services that are deemed to be medical services Services and supplies received from a hospital Charges which the person is not legally required to pay Charges made by a hospital which performs services for the U.S. Government if the charges are directly related to a condition connected to a military service Experimental or investigational procedures and treatments Any injury resulting from, or in the course of, any employment for wage or profit Any sickness covered under any workers compensation or similar law 6 To the extent that payment is unlawful where the person resides when the expenses are incurred; Procedures performed by a Dentist who is a member of the covered person s family (Covered person s family is limited to a spouse, siblings, parents, children, grandparents, and the spouse s siblings and parents); For charges which would not have been made if the person had no insurance; For charges for unnecessary care, treatment or surgery; To the extent that you or any of your Dependents is in any way paid or entitled to payment for those expenses by or through a public program, other than Medicaid; To the extent that benefits are paid or payable for those expenses under the mandatory part of any auto insurance policy written to comply with a no-fault insurance law or an uninsured motorist insurance law. Cigna HealthCare will take into account any adjustment option chosen under such part by you or any one of your Dependents. In addition, these benefits will be reduced so that the total payment will not be more than 100% of the charge made for the Dental Service if benefits are provided for that service under this plan and any medical expense plan or prepaid treatment program sponsored or made available by your Employer.

7 STATE OF CONNECTICUT ENHANCED PLAN Effective Date: July 01, 2016 This is a summary of benefits for your dental plan. Maximum CIGNA DENTAL NETWORK BENEFITS Dental Implants $500 Orthodontia $1,500 Per Member Lifetime Maximum All other categories (Except those noted above) $3,000 Calendar Year Deductible Per Individual $25 Per Family $75 Preventive & Diagnostic Care Cleanings Limit: Two per calendar year Exams Limit: Two per calendar year Bitewing X-Rays Limit: One per calendar year Non-Routine X-Rays Once every five calendar years Periodontal Maintenance Two per calendar year* Fluoride Application- Under age 16 two per calendar year Sealants Under age 16, one treatment per tooth every three years Basic Restorative Care Fillings** Minor and Major Periodontal Brush Biopsy Emergency Care to Relieve Pain Oral Surgery Simple Extractions Root Canal Therapy/Endodontics Surgical Extraction of Impacted Teeth Oral Surgery All Except Simple Extraction Relines, Rebases, and Adjustments Allowable six months after install Repairs Bridges, Crowns, and Inlays Repairs Dentures Space Maintainers (Limited to non-orthodontic treatment) Major Restorative Care Crowns/Inlays/Onlays Replacement every seven years Stainless Steel/Resin Crowns Replacement every seven years Prosthetics Plan Pays 100%, No Deductible Bridges (Replacement every seven years) Dentures (Replacement every seven years) 50% Implants 50%, to a maximum of $500 Orthodontia Coverage for children & adults Pretreatment Review 80% 67% 50%, No Deductible ($1,500 per member lifetime maximum) Voluntary basis when extensive work in excess of $200 is proposed. * If enrolled in HEP, maximums are waived on Periodontal Maintenance and Periodontal Scaling and Root Planning procedures. Deductible waived on certain procedures. ** For fillings other than amalgam, an alternate benefit may apply. Reimbursement based on Maximum Allowable Charge if using an Out-of-Network dentist. Where allowed by state law, in-network providers will charge no more than negotiated rate for non-covered services Please refer to the Summary Plan Description posted at for a full list of covered benefits, exclusions and limitations.

8 Procedure Exclusions & Limitations EXCLUSIONS AND LIMITATIONS Exams Two routine and two periodontal cleanings per calendar year Prophylaxis (Cleanings) Two per calendar year Fluoride 2 per calendar year for people under 16 X-Rays(routine) Bitewings: 1 per calendar year X-Rays (Non-routine) Full mouth: 1 every 5 calendar year. Panorex: 1 every 5 calendar year Model Payable only when in conjunction with Ortho workup Minor Perio (Non-surgical) Various limitations depending on the service, Frequency limit of once per 24 months Perio Surgery Various limitations depending on the service, Frequency limit of once per 36 months Crowns and Inlays Replacement every 7 years Prosthesis Over Implants 1 per every 7 years if unserviceable and cannot be repaired. Benefits are based on the amount payable for non-precious metals. No porcelain or white/tooth colored material on molar crowns or bridges. Bridges Replacement every 7 years Dentures and Partials Replacement every 7 years Relines, Rebases Covered if more than 6 months after installation Adjustments Covered if more than 6 months after installation Repairs - Bridges Reviewed if more than once Repairs - Dentures Reviewed if more than once Sealants Limited to posterior tooth. One treatment per tooth every three years up to age 16 Space Maintainers Limited to non-orthodontic treatment Alternate Benefit When more than one covered Dental Service could provide suitable treatment based on common dental standards, Cigna HealthCare will determine the covered Dental Service on which payment will be based and the expenses that will be included as Covered Expenses. Benefit Exclusions: Services performed primarily for cosmetic reasons Replacement of a lost or stolen appliance Replacement of a bridge or denture within seven years following the date of its original installation Replacement of a bridge or denture which can be made useable according to accepted dental standards Procedures, appliances or restorations, other than full dentures, whose main purpose is to change vertical dimension, diagnose or treat conditions of TMJ, stabilize periodontally involved teeth, or restore occlusion Veneers of porcelain or acrylic materials on crowns or pontics on or replacing the upper and lower first, second and third molars Bite registrations; precision or semi-precision attachments; splinting Instruction for plaque control, oral hygiene and diet Dental services that do not meet common dental standards Services that are deemed to be medical services Services and supplies received from a hospital Charges which the person is not legally required to pay Charges made by a hospital which performs services for the U.S. Government if the charges are directly related to a condition connected to a military service Experimental or investigational procedures and treatments Any injury resulting from, or in the course of, any employment for wage or profit 8 Any sickness covered under any workers compensation or similar law Charges in excess of the reasonable and customary allowances To the extent that payment is unlawful where the person resides when the expenses are incurred; Procedures performed by a Dentist who is a member of the covered person s family (Covered person s family is limited to a spouse, siblings, parents, children, grandparents, and the spouse s siblings and parents); For charges which would not have been made if the person had no insurance; For charges for unnecessary care, treatment or surgery; To the extent that you or any of your Dependents is in any way paid or entitled to payment for those expenses by or through a public program, other than Medicaid; To the extent that benefits are paid or payable for those expenses under the mandatory part of any auto insurance policy written to comply with a no-fault insurance law or an uninsured motorist insurance law. Cigna HealthCare will take into account any adjustment option chosen under such part by you or any one of your Dependents. In addition, these benefits will be reduced so that the total payment will not be more than 100% of the charge made for the Dental Service if benefits are provided for that service under this plan and any medical expense plan or prepaid treatment program sponsored or made available by your Employer.

9 CIGNA DENTAL CARE DHMO 1 ECONOMICAL, EASY-TO-USE DENTAL COVERAGE State of Connecticut SCT19 Under your plan, you have coverage for hundreds of dental procedures. This overview shows the list of covered services and what you will pay when you visit a participating DHMO network dentist. 2 Review your plan materials to understand how your plan works. For questions on the plan before enrollment, or to ask for a full list of covered services and exclusions and limitations, call 800.Cigna24 ( ) and select the Enrollment Information prompt. Regular dental visits may do more than brighten your smile. Receiving regular dental care often catches minor problems before they become major and more expensive to treat. And there s an association between gum disease and other conditions, such as preterm birth, heart disease, stroke, diabetes and other health issues. So taking good care of your teeth and gums may help you live a healthier life. Get the most value from your plan Take advantage of your plan s preventive care services Most are covered at low cost or no cost to you. Your plan also covers many other dental services that can help you achieve and maintain a healthy mouth. Key plan features No deductibles you don t have to reach a certain level of out-of-pocket expenses before your insurance kicks in. No dollar maximums you don t have to worry about your coverage running out after your covered expenses reach a certain dollar amount. Easy to understand plan the fees you pay your dentist are clearly listed on your Patient Charge Schedule (PCS). There are no claim forms to file and no waiting periods for coverage. The network general dentist you choose will manage your overall dental care. Covered family members can choose their own network general dentists near home, work or school. You don t need a referral for children under seven to visit a network pediatric dentist. And you don t need a referral to see a network orthodontist. There s no age limit on sealants, which help prevent tooth decay. Your plan covers certain procedures to help detect oral cancer in its early stages. 24/7 access to the Dental Information Line, staffed by trained professionals who can help if you have questions about dental treatment and clinical symptoms. Finding a network dentist is easy. There are several ways to select your network general dentist: Go to the Provider Directory at mycigna.com, or mycigna mobile app. Our online dental directory is updated weekly. Call 800.Cigna24 ( ) to speak to a customer service representative. Our representatives can send you a customized dental directory listing via if you d like. 9

10 Make sure you read this important information WHAT S COVERED You can save money on a wide range of services, including: Preventive care cleanings, fluoride, sealants, bitewing X- rays, full mouth X-rays, and more Basic care tooth-colored fillings (Called resin or composite) and silver-colored fillings (Called amalgam) Major services crowns, bridges, and dentures, root canals, oral surgery, extractions, treatment for periodontal (Gum) disease, and more Specialty care At the same fee as general care, with an approved referral Orthodontic care braces for children and adults General anesthesia when medically necessary Teeth whitening using take-home bleaching trays and gel Age and frequency limitations may apply to some covered services. Review the full DHMO Patient Charge Schedule below for details. See following pages for covered procedures and patient charges. Code Procedure Description SCTI9 Diagnostic/preventive Oral evaluations are limited to a combined total of 4 of the following evaluations during a 12 consecutive month period: Periodic oral evaluations (D0120), comprehensive oral evaluations (D0150), comprehensive periodontal evaluations (D0180), and oral evaluations for patients under 3 years of age (D0145). D9310 Consultation (Diagnostic service provided by dentist or physician other than requesting dentist or physician) D9430 Office visit for observation No other services performed D9450 Case presentation Detailed and extensive treatment planning D0120 Periodic oral evaluation Established patient D0140 Limited oral evaluation Problem focused D0145 Oral evaluation for a patient under 3 years of age and counseling with primary caregiver D0150 Comprehensive oral evaluation New or established patient D0160 Detailed and extensive oral evaluation problem focused, by report (Limit 2 per calendar year; only covered in conjunction with Temporomandibular Joint (TMJ) evaluation) D0170 Reevaluation Limited, problem focused (Not postoperative visit) D0180 Comprehensive periodontal evaluation New or established patient D0210 X-rays intraoral Complete series of radiographic images (Limit 1 every 3 years) $45.00 Code Procedure Description SCTI9 D0220 X-rays intraoral Periapical First radiographic image D0230 X-rays intraoral Periapical Each additional radiographic image D0240 X-rays intraoral Occlusal radiographic image D0270 X-rays (Bitewing) Single radiographic image D0272 X-rays (Bitewings) 2 radiographic images D0273 X-rays (Bitewings) 3 radiographic images D0274 X-rays (Bitewings) 4 radiographic images D0277 X-rays (Bitewings, vertical) 7 to 8 radiographic images D0330 X-rays (Panoramic radiographic image) (Limit 1 every 3 years) D0364 Cone beam CT capture and interpretation with limited field of view less than one whole jaw (Only covered in conjunction with the surgical placement of an implant; limit of a total of only one D0364, D0365, D0366, or D0367 per calendar year) D0365 Cone beam CT capture and interpretation with field of view of one full dental arch Mandible (Only covered in conjunction with the surgical placement of an implant; limit of a total of only one D0364, D0365, D0366, or D0367 per calendar year) $ $

11 Code Procedure Description SCTI9 D0366 Cone beam CT capture and interpretation with $ field of view of one full dental arch Maxilla, with or without cranium (Only covered in conjunction with the surgical placement of an implant; limit of a total of only one D0364, D0365, D0366, or D0367 per calendar year) D0367 Cone beam CT capture and interpretation with $ field of view of both jaws, with or without cranium (Only covered in conjunction with the surgical placement of an implant; limit of a total of only one D0364, D0365, D0366, or D0367 per calendar year) D0368 Cone beam CT capture and interpretation for $ TMJ series including two or more exposures (Limit 1 per calendar year; only covered in conjunction with Temporomandibular Joint (TMJ) evaluation) D0431 Oral cancer screening using a special light source $50.00 D0460 Pulp vitality tests $14.00 D0470 Diagnostic casts D0472 Pathology report Gross examination of lesion (Only when tooth related) D0473 Pathology report Microscopic examination of lesion (Only when tooth related) D0474 Pathology report Microscopic examination of lesion and area (Only whentooth related) D1110 Prophylaxis (Cleaning) Adult (Limit 2 per calendar year) Additional prophylaxis (Cleaning) In addition $45.00 to the 2 prophylaxes (Cleanings) allowed per calendar year D1120 Prophylaxis (Cleaning) Child (Limit 2 per calendar year) Additional prophylaxis (Cleaning) In addition to the 2 $30.00 prophylaxes (Cleanings) allowed per calendar year Coverage for treatment by a Pediatric Dentist ends on your child s 7th birthday; however, exceptions for medical reasons may be considered on an individual basis. Your Network General Dentist will provide care upon your child s 7th birthday. D1206 Topical application of fluoride varnish (Limit 2 per calendar year). There is a combined limit of a total of 2 D1206s and/or D1208s per calendar year. Code Procedure Description SCTI9 Additional topical application of fluoride varnish in addition $15.00 to any combination of two (2) D1206s (Topical application of fluoride varnish) and/or D1208s (Topical application of fluoride) per calendar year. D1208 Topical application of fluoride Excluding varnish (Limit 2 per calendar year ) There is a combined limit of a total of 2 D1208s and/or D1206s per calendar year. Additional topical application of fluoride Excluding varnish $15.00 in addition to any combination of two (2) D1206s (Topical applications of fluoride varnish) and/or D1208s (Topical application of fluoride) per calendar year D1330 Oral hygiene instructions D1351 Sealant Per tooth $17.00 D1352 Preventive resin restoration in a moderate to $17.00 high caries risk patient Permanent tooth D1510 Space maintainer Fixed Unilateral $ D1515 Space maintainer Fixed Bilateral $ D1555 Removal of fixed space maintainer Restorative (Fillings, including polishing) D2140 Amalgam 1 surface, primary or permanent $6.00 D2150 Amalgam 2 surfaces, primary or permanent $6.00 D2160 Amalgam 3 surfaces, primary or permanent $12.00 D2161 Amalgam 4 or more surfaces, primary $18.00 or permanent D2330 Resin-based composite 1 surface, anterior $6.00 D2331 Resin-based composite 2 surfaces, anterior $13.00 D2332 Resin-based composite 3 surfaces, anterior $18.00 D2335 Resin-based composite 4 or more surfaces or $88.00 involving incisal angle, anterior D2390 Resin-based composite crown, anterior $88.00 D2391 Resin-based composite 1 surface, posterior $47.00 D2392 Resin-based composite 2 surfaces, posterior $59.00 D2393 Resin-based composite 3 surfaces, posterior $82.00 D2394 Resin-based composite 4 or more surfaces, posterior $

12 Code Procedure Description SCTI9 Crown and bridge All charges for crown and bridge (Fixed partial denture) are per unit (Each replacement or supporting tooth equals 1 unit). Coverage for replacement of crowns and bridges is limited to 1 every 5 years Per tooth charge for crowns, inlays, onlays, post and cores, and veneers if your dentist uses same day in-office CAD/CAM (Ceramic) Services. Same day in- office CAD/CAM (Ceramic) Services refer to dental restorations that are created in the dental office by the use of a digital impression and an in-office CAD/CAM milling machine. $ D2510 Inlay Metallic 1 surface $ D2520 Inlay Metallic 2 surfaces $ D2530 Inlay Metallic 3 or more surfaces $ D2542 Onlay Metallic 2 surfaces $ D2543 Onlay Metallic 3 surfaces $ D2544 Onlay Metallic 4 or more surfaces $ D2740 Crown Porcelain/ceramic substrate $ D2750 Crown Porcelain fused to high noble metal $ D2751 Crown Porcelain fused to predominantly $ base metal D2752 Crown Porcelain fused to noble metal $ D2780 Crown 3/4 cast high noble metal $ D2781 Crown 3/4 cast predominantly base metal $ D2782 Crown 3/4 cast noble metal $ D2790 Crown Full cast high noble metal $ D2791 Crown Full cast predominantly base metal $ D2792 Crown Full cast noble metal $ D2794 Crown Titanium $ D2910 Re-cement or re-bond inlay, onlay, veneer or $12.00 partial coverage restoration D2915 Re-cement or re-bond cast indirectly fabricated $12.00 or prefabricated post and core D2920 Re-cement or re-bond crown $12.00 D2929 Prefabricated porcelain/ceramic crown $ Primary tooth D2930 Prefabricated stainless steel crown $92.00 Primary tooth D2931 Prefabricated stainless steel crown $92.00 Permanent tooth D2932 Prefabricated resin crown $ D2933 Prefabricated stainless steel crown with resin window $ Code Procedure Description SCTI9 D2934 Prefabricated esthetic coated stainless steel $ crown Primary tooth D2940 Protective restoration $13.00 D2950 Core buildup Including any pins when required $97.00 D2951 Pin retention Per tooth In addition $18.00 to restoration D2952 Post and core In addition to crown, $ indirectly fabricated D2954 Prefabricated post and core In addition $ to crown D2960 Labial veneer (resin laminate) Chairside $ D6210 Pontic Cast high noble metal $ D6211 Pontic Cast predominantly base metal $ D6212 Pontic Cast noble metal $ D6214 Pontic Titanium $ D6240 Pontic Porcelain fused to high noble metal $ D6241 Pontic Porcelain fused to predominantly $ base metal D6242 Pontic Porcelain fused to noble metal $ D6245 Pontic Porcelain/ceramic $ D6602 Retainer inlay Cast high noble metal, $ surfaces D6603 Retainer inlay Cast high noble metal, 3 or $ more surfaces D6604 Retainer inlay Cast predominantly base metal, $ surfaces D6605 Retainer inlay Cast predominantly base metal, $ or more surfaces D6606 Retainer inlay Cast noble metal, 2 surfaces $ D6607 Retainer inlay Cast noble metal, 3 or $ more surfaces D6610 Retainer onlay Cast high noble metal, 2 surfaces $ D6611 Retainer onlay Cast high noble metal, 3 or $ more surfaces D6612 Retainer onlay Cast predominantly base $ metal, 2 surfaces D6613 Retainer onlay Cast predominantly base $ metal, 3 or more surfaces D6614 Retainer onlay Cast noble metal, 2 surfaces $ D6615 Retainer onlay Cast noble metal, 3 or $ more surfaces D6624 Retainer inlay Titanium $

13 Code Procedure Description SCTI9 D6634 Retainer onlay Titanium $ D6740 Retainer crown Porcelain/ceramic $ D6750 Retainer crown Porcelain fused to high $ noble metal D6751 Retainer crown Porcelain fused to $ predominantly base metal D6752 Retainer crown Porcelain fused to noble metal $ D6780 Retainer crown 3/4 cast high noble metal $ D6781 Retainer crown 3/4 cast predominantly $ base metal D6782 Retainer crown 3/4 cast noble metal $ D6790 Retainer crown Full cast high noble metal $ D6791 Retainer crown Full cast predominantly $ base metal D6792 Retainer crown Full cast noble metal $ D6794 Retainer crown Titanium $ Complex rehabilitation Additional charge per unit for multiple $ crown units/complex rehabilitation (6 or more units of crown and/or bridge in same treatment plan requires complex rehabilitation for each unit Ask your dentist for the guidelines) D6930 Re-cement or re-bond fixed partial denture $12.00 Endodontics (Root canal treatment, excluding final restorations) D3110 Pulp cap Direct (Excluding final restoration) $14.00 D3120 Pulp cap Indirect (Excluding final restoration) $14.00 D3220 Pulpotomy Removal of pulp, not part of a root canal D3221 Pulpal debridement, primary and permanent (Not to be used when root canal is done on the same day ) D3222 Partial pulpotomy for apexogenesis Permanent tooth with incomplete root development D3310 Anterior root canal Permanent tooth (Excluding final restoration) D3320 Bicuspid root canal Permanent tooth (Excluding final restoration) D3330 Molar root canal Permanent tooth (Excluding final restoration) D3331 Treatment of root canal obstruction Nonsurgical access D3332 Incomplete endodontic therapy Inoperable, unrestorable or fractured tooth $89.00 $83.00 $89.00 $ $ $ $ $ Code Procedure Description SCTI9 D3333 Internal root repair of perforation defects $ D3346 Retreatment of previous root canal $ therapy Anterior D3347 Retreatment of previous root canal $ therapy Bicuspid D3348 Retreatment of previous root canal therapy Molar $ D3410 Apicoectomy/periradicular surgery Anterior $ D3421 Apicoectomy/periradicular surgery Bicuspid $ (First root) D3425 Apicoectomy/periradicular surgery $ Molar (First root) D3426 Apicoectomy/periradicular surgery (Each $ additional root) D3430 Retrograde filling per root $89.00 Periodontics (Treatment of supporting tissues [gum and bone] of the teeth) periodontal regenerative procedures are limited to 1 regenerative procedure per site (Or per tooth, if applicable), when covered on the patient charge schedule. The relevant procedure codes are D4263, D4264, D4266 and D4267. Localized delivery of antimicrobial agents is limited to 8 teeth (Or 8 sites, if applicable) per 12 consecutive months when covered on the patient charge schedule. D4210 Gingivectomy or gingivoplasty 4 or more $ contiguous teeth or tooth bounded spaces per quadrant D4211 Gingivectomy or gingivoplasty 1 to 3 $ contiguous teeth or tooth bounded spaces per quadrant D4212 Gingivectomy or gingivoplasty to allow access $ for restorative procedure, per tooth D4240 Gingival flap (Including root planing) 4 or $ more contiguous teeth or tooth bounded spaces per quadrant D4241 Gingival flap (Including root planing) 1 to 3 $ contiguous teeth or tooth bounded spaces per quadrant D4245 Apically positioned flap $ D4249 Clinical crown lengthening Hard tissue $ D4260 D4261 Osseous surgery (Including elevation of a full thickness flap and closure) 4 or more contiguous teeth or tooth bounded spaces per quadrant Osseous surgery (Including elevation of a full thickness flap and closure) 1 to 3 contiguous teeth or tooth bounded spaces per quadrant $ $

14 Code Procedure Description SCTI9 D4263 Bone replacement graft First site in quadrant $ D4264 Bone replacement graft Each additional site $ in quadrant D4266 Guided tissue regeneration Resorbable barrier $ per site D4267 Guided tissue regeneration Nonresorbable $ barrier per site (Includes membrane removal) D4270 Pedicle soft tissue graft procedure $ D4275 Non-autogenous connective tissue graft $ (Including recipient site and donor material) first tooth, implant, or edentulous tooth position in graft D4277 Free soft tissue graft procedure (Including $ recipient donor surgical sites), first tooth implant or edentulous (Missing) tooth position in graft D4278 Free soft tissue graft procedure (Including $ recipient and donor surgical sites), each additional contiguous tooth, implant or edentulous (Missing ) tooth position in same graft site D4341 Periodontal scaling and root planing 4 or $ more teeth per quadrant (Limit 4 quadrants per consecutive 12 months) D4342 Periodontal scaling and root planing 1 to 3 $60.00 teeth Per quadrant (Limit 4 quadrants per consecutive 12 months) D4355 Full mouth debridement to allow evaluation and $84.00 diagnosis (1 per lifetime) D4381 Localized delivery of antimicrobial agents per tooth $45.00 D4910 Periodontal maintenance (Only covered after active periodontal therapy) $77.00 Prosthetics (Removable tooth replacement dentures) includes up to 4 adjustments within first 6 months after insertion Replacement limit 1 every 5 years. D5110 Full upper denture $ D5120 Full lower denture $ D5130 Immediate full upper denture $ D5140 Immediate full lower denture $ D5211 D5212 D5213 Upper partial denture Resin base (Including clasps, rests and teeth) Lower partial denture Resin base (Including clasps, rests and teeth) Upper partial denture Cast metal framework (Including clasps, rests and teeth) $ $ $ Code Procedure Description SCTI9 D5214 Lower partial denture Cast metal framework $ (Including clasps, rests and teeth) D5225 Upper partial denture Flexible base (Including $ clasps, rests and teeth) D5226 Lower partial denture Flexible base (Including $ clasps, rests and teeth) D5410 Adjust complete denture Upper $38.00 D5411 Adjust complete denture Lower $38.00 D5421 Adjust partial denture Upper $38.00 D5422 Adjust partial denture Lower $38.00 Repairs to prosthetics D5510 Repair broken complete denture base $71.00 D5520 Replace missing or broken teeth Complete $71.00 denture (Each tooth) D5610 Repair resin denture base $71.00 D5630 Repair or replace broken clasp Per tooth $88.00 D5640 Replace broken teeth Per tooth $71.00 D5650 Add tooth to existing partial denture $71.00 D5660 Add clasp to existing partial denture Per tooth $88.00 Denture relining (Limit 1 every 36 months) D5710 Rebase complete upper denture $ D5711 Rebase complete lower denture $ D5720 Rebase upper partial denture $ D5721 Rebase lower partial denture $ D5730 Reline complete upper denture Chairside $ D5731 Reline complete lower denture Chairside $ D5740 Reline upper partial denture Chairside $ D5741 Reline lower partial denture Chairside $ D5750 Reline complete upper denture Laboratory $ D5751 Reline complete lower denture Laboratory $ D5760 Reline upper partial denture Laboratory $ D5761 Reline lower partial denture Laboratory $ Interim dentures (Limit 1 every 5 years) D5810 Interim complete denture Upper $ D5811 Interim complete denture Lower $ D5820 Interim partial denture Upper $ D5821 Interim partial denture Lower $

15 Code Procedure Description SCTI9 Implant Services Surgical Placement of Implants (D6010, D6012, D6040, and D6050 have a limit of 1 implant per calendar year with a replacement of 1 per 10 years) D6010 Surgical placement of implant body: $1, Endosteal implant D6012 Surgical placement of interim implant body for $ transitional prosthesis: Endosteal implant D6040 Surgical placement: Eposteal implant $ D6050 Surgical placement: Transosteal implant $ D6055 Connecting bar - Implant supported or abutment supported (Limit 1 per calendar year) D6056 Prefabricated abutment - Includes modification and placement (Limit 1 per calendar year) D6057 Custom fabricated abutment - Includes placement (Limit 1 per calendar year) D6080 Implant maintenance procedures, including removal of prosthesis, cleansing of prosthesis and abutments and reinsertion of prosthesis (Limit 1 per calendar year) D6090 Repair implant supported prosthesis, by report (Limit 1 per calendar year) D6091 Replacement of semi-precision or precision attachment (male or female component) of implant/abutment supported prosthesis, per attachment (Limit 1 per calendar year) D6095 Repair implant abutment, by report (Limit 1 per calendar year) D6100 Implant removal, by report (Limit 1 per calendar year) D6101 Debridement of a periimplant defect or defects surrounding a single implant, and surface cleaning of the exposed implant surfaces, including flap entry and closure (Limit 1 per calendar year) D6102 Debridement and osseous contouring of a periimplant defect or defects surrounding a single implant; includes surface cleaning of exposed implant surfaces and flap entry and closure (Limit 1 per calendar year) D6103 Bone graft for repair of periimplant defect does not including flap entry and closure (limit 1 per calendar year) D6104 Bone graft at time of implant placement (Limit 1 per calendar year) $1, $ $ $65.00 $ $60.00 $ $ $ $ $ $ Code Procedure Description SCTI9 D6190 Radiographic/surgical implant index, by report $ (Limit 1 per calendar year) Implant/abutment supported prosthetics All charges for crown and bridge (Fixed partial denture) are per unit (Each replacement on a supporting implant(s) equals 1 unit). Coverage for replacement of crowns and bridges and implant supported dentures is limited to 1 every 5 years. Per tooth charge for crowns, inlays, onlays, post and cores, $ and veneers if your dentist uses same day in-office CAD/CAM (Ceramic) Services. Same day in- office CAD/CAM (Ceramic) Services refer to dental restorations that are created in the dental office by the use of a digital impression and an in-office CAD/CAM milling machine. D6058 Abutment supported porcelain/ceramic crown $ D6059 Abutment supported porcelain fused to metal $ crown (High noble metal) D6060 Abutment supported porcelain fused to metal $ crown (Predominantly base metal) D6061 Abutment supported porcelain fused to metal $ crown (Noble metal) D6062 Abutment supported cast metal crown $ (High noble metal) D6063 Abutment supported cast metal crown $ (Predominantly base metal) D6064 Abutment supported cast metal crown $ (Noble metal) D6065 Implant supported porcelain/ceramic crown $ D6066 D6067 D6068 D6069 D6070 D6071 D6072 D6073 Implant supported porcelain fused to metal crown (Titanium, titanium alloy, high noble metal) Implant supported metal crown (Titanium, titanium alloy, high noble metal) Abutment supported retainer for porcelain/ceramic fixed partial denture Abutment supported retainer for porcelain fused to metal fixed partial denture (High noble metal) Abutment supported retainer for porcelain fused to metal fixed partial denture (Predominantly base metal) Abutment supported retainer for porcelain fused to metal fixed partial denture (Noble metal) Abutment supported retainer for cast metal fixed partial denture (High noble metal) Abutment supported retainer for cast metal fixed partial denture (Predominantly base metal) $ $ $ $ $ $ $ $

16 Code Procedure Description SCTI9 D6074 Abutment supported retainer for cast metal fixed partial denture (Noble metal) $ D6075 Implant supported retainer for ceramic fixed $ partial denture D6076 Implant supported retainer for porcelain fused to $ metal fixed partial denture (Titanium, titanium alloy, high noble metal) D6077 Implant supported retainer for cast metal fixed $ partial denture (Titanium, titanium alloy, high noble metal) D6092 Re-cement or re-bond implant/abutment $51.00 supported crown D6093 Re-cement or re-bond implant/abutment $51.00 supported fixed partial denture D6094 Abutment supported crown (Titanium) $ D6110 Implant /abutment supported removable denture for edentulous arch Maxillary D6111 Implant /abutment supported removable denture for edentulous arch Mandibular D6112 Implant /abutment supported removable denture for partially edentulous arch Maxillary D6113 Implant /abutment supported removable denture for partially edentulous arch Mandibular D6114 Implant /abutment supported fixed denture for edentulous arch Maxillary D6115 Implant /abutment supported fixed denture for edentulous arch Mandibular D6116 Implant /abutment supported fixed denture for partially edentulous arch Maxillary D6117 Implant /abutment supported fixed denture for partially edentulous arch Mandibular D6194 Abutment supported retainer crown for fixed partial denture (Titanium) Complex rehabilitation on implant/abutment supported prosthetic procedures Additional charge per unit for multiple crown units/complex rehabilitation (6 or more units of crown and/or bridge in same treatment plan requires complex rehabilitation for each unit Ask your dentist for the guidelines) $ $ $ $ $ $ $ $ $ $ Oral surgery (Includes routine postoperative treatment) Surgical removal of impacted tooth Not covered for ages below 15 unless pathology (Disease) exists. D7111 Extraction of coronal remnants Deciduous tooth D7140 Extraction, erupted tooth or exposed root Elevation and/or forceps removal $12.00 Code Procedure Description SCTI9 D7210 Surgical removal of erupted tooth Removal of $89.00 bone and/or section of tooth D7220 Removal of impacted tooth Soft tissue $71.00 D7230 Removal of impacted tooth Partially bony $ D7240 Removal of impacted tooth Completely bony $ D7241 Removal of impacted tooth Completely bony, $ unusual complications(narrative required) D7250 Surgical removal of residual tooth roots $89.00 Cutting procedure D7251 Coronectomy Intentional partial $ tooth removal D7260 Oroantral fistula closure $ D7261 Primary closure of a sinus perforation $ D7270 Tooth re-implantation and/or stabilization of $14.00 accidentally evulsed or displaced tooth D7280 Surgical access of an unerupted tooth $14.00 (Excluding wisdom teeth) D7283 Placement of device to facilitate eruption of $8.00 impacted tooth D7285 Incisional biopsy of oral tissue - Hard (Bone, $ tooth) (Tooth related - not allowed when in conjunction with another surgical procedure) D7286 Incisional biopsy of oral tissue - Soft (all $ others) (Tooth related - not allowed when in conjunction with another surgical procedure) D7287 Exfoliative cytological sample collection $78.00 D7288 Brush biopsy Transepithelial sample collection $78.00 D7310 Alveoloplasty in conjunction with extractions $ or more teeth or tooth spaces per quadrant D7311 Alveoloplasty in conjunction with extractions $ to 3 teeth or tooth spaces per quadrant D7320 Alveoloplasty not in conjunction with $ extractions 4 or more teeth or tooth spaces per quadrant D7321 Alveoloplasty not in conjunction with $64.00 extractions 1 to 3 teeth or tooth spaces per quadrant D7450 Removal of benign odontogenic cyst or tumor $14.00 Up to 1.25 cm D7451 Removal of benign odontogenic cyst or tumor $14.00 Greater than 1.25 cm D7471 Removal of lateral exostosis Maxilla or mandible $14.00 D7472 Removal of torus palatinus $14.00 D7473 Removal of torus mandibularis $

17 Code Procedure Description SCTI9 D7485 Surgical reduction of osseous tuberosity $ D7510 Incision and drainage of abscess Intraoral $14.00 soft tissue D7511 Incision and drainage of abscess Intraoral soft $20.00 tissue Complicated D7880 Occlusal orthotic device, by report - (Limit 1 per $ months; only covered in conjunction with Temporomandibular Joint (TMJ) treatment) D7951 Sinus augmentation with bone or bone $ substitutes via a lateral open approach (Limit 1 per calendar year; only covered in conjunction with the surgical placement of implant) D7952 Sinus augmentation via a vertical approach (Limit $ per calendar year; only covered in conjunction with the surgical placement of implant) D7953 Bone replacement graft for ridge preservation - $ per site (Limit 1 per calendar year; only covered in conjunction with the surgical placement of implant) D7960 Frenulectomy Also known as frenectomy or $14.00 frenotomy Separate procedure not incidental to another procedure D7963 Frenuloplasty $20.00 Orthodontics (Tooth movement) Orthodontic treatment (Maximum benefit of 24 months of interceptive and/or comprehensive treatment. Atypical cases or cases beyond 24 months require an additional payment by the patient.) D8050 Interceptive orthodontic treatment of the $ primary dentition Banding D8060 Interceptive orthodontic treatment of the $ transitional dentition Banding D8070 Comprehensive orthodontic treatment of the $ transitional dentition Banding D8080 Comprehensive orthodontic treatment of the $ adolescent dentition Banding D8090 Comprehensive orthodontic treatment of the $ adult dentition Banding D8660 Pre-orthodontic treatment examination to $67.00 monitor growth and development D8670 Periodic orthodontic treatment visit Children Up to 19th birthday: 24-month treatment fee $2, Charge per month for 24 months $95.00 Code Procedure Description SCTI9 Adults: 24-month treatment fee $3, Charge per month for 24 months $ D8680 Orthodontic retention Removal of appliances, $ construction and placement of retainer(s) D8999 Unspecified orthodontic procedure By report (Orthodontic treatment plan and records) $ General anesthesia/iv sedation General anesthesia is covered when performed by an oral surgeon when medically necessary for covered procedures listed on the patient charge schedule. IV sedation is covered when performed by a periodontist or oral surgeon when medically necessary for covered procedures listed on the patient charge schedule. Plan limitation for this benefit is 1 hour per appointment. There is no coverage for general anesthesia or intravenous sedation when used for the purpose of anxiety control or patient management. D9223 Deep sedation/general anesthesia each 15 $90.00 minute increment D9243 Intravenous moderate (Conscious) sedation/ analgesia each 15 minute increment $90.00 Emergency services D9110 Palliative (Emergency) treatment of dental pain Minor procedure D9440 Office visit After regularly scheduled hours $66.00 Miscellaneous services D9940 Occlusal guard By report $ (Limit 1 per 24 months) D9941 Fabrication of athletic mouthguard $ (Limit 1 per 12 months) D9951 Occlusal adjustment Limited $58.00 D9952 Occlusal adjustment Complete $ D9975 External bleaching for home application, per arch; includes materials and fabrication of custom trays (All other methods of bleaching are not covered) $ This may contain CDT codes and/or portions of, or excerpts from the nomenclature contained within the Current Dental Terminology, a copyrighted publication provided by the American Dental Association. The American Dental Association does not endorse any codes which are not included in its current publication. 17

18 Listed below are the services or expenses which are NOT covered under your Dental Plan and which are your responsibility at the dentist s usual fees. There is no coverage for: Or in connection with an injury arising out of, or in the course of, any employment for wage or profit Charges which would not have been made in any facility, other than a hospital or a correctional institution owned or operated by the united states government or by a state or municipal government if the person had no insurance To the extent that payment is unlawful where the person resides when the expenses are incurred or the services are received The charges which the person is not legally required to pay Charges which would not have been made if the person had no insurance Due to injuries which are intentionally self-inflicted Services not listed on the PCS Services provided by a non-network dentist without Cigna Dental s prior approval (Except emergencies, as described in your plan documents) 3 Services related to an injury or illness paid under workers compensation, occupational disease or similar laws Services provided or paid by or through a federal or state governmental agency or authority, political subdivision or a public program, other than medicaid Services required while serving in the armed forces of any country or international authority or relating to a declared or undeclared war or acts of war Services performed primarily for cosmetic reasons unless specifically listed on your PCS General anesthesia, sedation and nitrous oxide, unless specifically listed on your PCS Prescription medications Replacement of fixed and/or removable appliances (including fixed and removable orthodontic appliances) that have been lost, stolen, or damaged due to patient abuse, misuse or neglect Surgical implant of any type unless specifically listed on your PCS Services considered to be unnecessary or experimental in nature or do not meet commonly accepted dental standards Procedures or appliances for minor tooth guidance or to control harmful habits Services and supplies received from a hospital The completion of crowns, bridges, dentures, or root canal treatment already in progress on the effective date of your Cigna Dental coverage 4 The completion of implant supported prosthesis (including crowns, bridges and dentures) already in progress on the effective date of your Cigna Dental coverage, unless specifically listed on your PCS 4 Consultations and/or evaluations associated with services that are not covered Endodontic treatment and/or periodontal (gum tissue and supporting bone) surgery of teeth exhibiting a poor or hopeless periodontal prognosis Bone grafting and/or guided tissue regeneration when performed at the site of a tooth extraction unless specifically listed on your PCS Bone grafting and/or guided tissue regeneration when performed in conjunction with an apicoectomy or periradicular surgery Intentional root canal treatment in the absence of injury or disease to solely facilitate a restorative procedure Services performed by a prosthodontist Localized delivery of antimicrobial agents when performed alone or in the absence of traditional periodontal therapy Any localized delivery of antimicrobial agent procedures when more than eight (8) of these procedures are reported on the same date of service. Infection control and/or sterilization The recementation of any inlay, onlay, crown, post and core or fixed bridge within 180 days of initial placement The recementation of any implant supported prosthesis (including crowns, bridges and dentures) within 180 days of initial placement Services to correct congenital malformations, including the replacement of congenitally missing teeth The replacement of an occlusal guard (Night guard) beyond one per any 24 consecutive month period, when this limitation is noted on the PCS Crowns, bridges and/or implant supported prosthesis used solely for splinting Resin bonded retainers and associated pontics Should any law require coverage for any particular service(s) noted above, the exclusion or limitation for that service(s) shall not apply. This document outlines the highlights of your plan. For a complete list of both covered and not-covered services,including benefits required by your state, see your insurance certificate or plan description. If there are any differences between the information contained here and the plan documents, the information in the plan documents takes precedence. 18

19 CIGNA DENTAL ORAL HEALTH INTEGRATION PROGAM How does it work? When you visit your dentist, you will pay your usual copay or coinsurance amount. As a reminder, your copay is the fixed amount you pay for covered services. And your coinsurance is the percentage of costs you pay for covered services. Next, your dentist will send Cigna a claim. We review the claim and will refund your copay or coinsurance for eligible services. Once we receive your claim, you can expect to be reimbursed in about 30 days. What is the Cigna Dental Oral Health Integration Program? It s a program that reimburses out-of-pocket costs for specific dental services used to treat or help prevent gum disease and tooth decay. The program is for people with certain medical conditions that may be impacted by dental care. There s no additional cost for the program if you qualify, you get reimbursed!* Do I qualify? If you have a Cigna dental plan, you re eligible for the program. The only requirement is that you re currently being treated by a doctor for: Heart disease Stroke Diabetes Maternity Chronic kidney disease Organ transplants Head and neck cancer radiation How do I enroll? 1. Fill out the registration form. This is required only one time per qualifying medical condition. You can find the form on the next page or the State of CT website. ( ct) under Understand Plan Coverage tab, in the Other Features section click OHIP registration form. Or by calling the number on your ID card. Remember to check off any additional information you may want about Cigna Home Delivery Pharmacy discounts and/or behaviors that can affect oral health. 2. Mail in your completed form to Cigna at the address listed on the registration form. 3. Visit your dentist and pay your usual copay or coinsurance amount for the covered service. We ll send your reimbursement in about 30 days. * You do not need to meet your plan s deductible to receive reimbursement for these services. However, any reimbursement you receive will apply to and is subject to your plan s annual maximum. If you have coverage for out-of-network services you may choose to visit an in-network or out-of-network dentist. However, remember that it s a good idea to use an in-network (Participating) dentist. Participating dentists have a contract with Cigna. This means you pay less. If you have any of these conditions, please fill out the form on the next page. Please note: The OHIP form is not used to enroll in dental benefits. 19

20 Cigna Dental Oral Health Integration Program Registration Form INSTRUCTIONS: Please complete the entire form to ensure registration. For questions on the program, please refer to back page. This form is for OHIP only and will not make changes to your dental coverage. Please mail the completed form to: Cigna Dental P.O. Box Chattanooga, TN Primary Customer Name: (Last, First, Middle Initial) A. PRIMARY CUSTOMER INFORMATION SSN or Cigna Customer ID: Address: (Street) (City) (State) (Zip Code) Telephone Number: Address: Employer Name: Employer Group Number: Patient Name: (Last, First, Middle Initial) B. PATIENT INFORMATION Patient Date of Birth: Patient's Relationship to the Primary Customer: Self Spouse Dependent Other C. MEDICAL INFORMATION AND ELIGIBLE PROCEDURES By checking the box(es) below, I confirm that based on the terms of my plan, I have one or more of the conditions listed and am eligible for this additional dental coverage. I understand that filling out and mailing this form does not guarantee payment and that plan maximums may apply. Cardiovascular Diabetes Organ Transplants Maternity (please list due date): Cerebrovascular (Stroke) Chronic Kidney Disease Head and Neck Cancer Radiation ELIGIBLE PROCEDURES Cardiovascular, Cerebrovascular (Stroke) and Diabetes: D Periodontal Scaling and Root Planing - 4 or more teeth per quadrant D Periodontal Scaling and Root Planing teeth per quadrant D Periodontal Maintenance* Chronic Kidney Disease, Organ Transplants and Head and Neck Cancer Radiation: D Topical Application of Fluoride Varnish*** D Topical Application of Fluoride - Excluding Varnish D Sealant - One Tooth*** D Sealant Repair - per tooth** D Periodontal Scaling and Root Planing - 4 or more teeth per quadrant D Periodontal Scaling and Root Planing teeth per quadrant D Periodontal Maintenance* * Limited to four times per year. ** One additional cleaning and one additional exam per year. *** Age limitations removed, all other limitations apply. Maternity: D Periodic Oral Evaluation** D Limited Oral Evaluation** D Comprehensive Oral Evaluation** D Periodontal Evaluation D Prophylaxis - Adult (Cleaning)** D Periodontal Maintenance* D Periodontal Scaling and Root Planing - 4 or more teeth per quadrant D Periodontal Scaling and Root Planing teeth per quadrant D Palliative Treatment D. HOW TO GET ADDITIONAL INFORMATION AVAILABLE TO CIGNA DENTAL ORAL HEALTH INTEGRATION PROGRAM CUSTOMERS I'd like to receive information on: Tobacco Cessation Fear of Dentist Stress and the Impact on Oral Health How to get free samples and discounts for non-prescription dental products developed for patients with a higher risk of oral health problems. I understand by checking this box that I authorize Cigna Dental to release my name and address for one-time use only to outside companies so they may provide me with information and products. How to get discounts on my prescription dental products from Cigna Home Delivery Pharmacy SM. Please select how you'd like us to send the information: Send to the address listed in Section A above Mail to me at no charge to the address listed in Section A above E. CERTIFICATION OF MEDICAL CONDITION I also understand Cigna has the right to check my medical records and contact my dentist and/or physician to confirm my medical condition. Medical Physician's Name: Telephone Number: Medical Carrier: PATIENT SIGNATURE: (Required) DATE: Participation in the Cigna Dental Oral Health Program does not guarantee coverage and is subject to the terms of customer's plan documents which shall prevail. Cat. #828310g Rev. 04/